Irene Akua Agyepong

Implementation research: what it is and how to do it.

Implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it

Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme

The public social policy and programme decisions that are made in low-income countries have critical effects on human social and development outcomes. Unfortunately, it would appear that inadequate attention is paid to analysing, understanding and factoring into attempts to reshape or change policy, the complex historical, social, cultural, economic, political, organizational and institutional context; actor interests, experiences, positions and agendas; and policy development processes that influence policy and programme choices. Yet these can be just as critical as the availability of research or other evidence in influencing decision making on policies and their accompanying programmes and the resulting degree of success or failure in achieving the original objectives. Ghana, a low-income developing country in sub-Saharan Africa, embarked on a national policy process of replacing out-of-pocket fees at point of service use with national health insurance in 2001. This paper uses a case study approach to describe and reflect on the complex interactions of context with actors and processes including political power play; and the effects on agenda setting, decision making and policy and programme content. This case study supports observations from the literature that although availability of evidence is critical, major public social policy and programme content can be heavily influenced by factors other than the availability or non-availability of evidence to inform content decision making. In the low-income developing country context there can be imbalances of policy decision-making power related to strong and dominant political actors combined with weak civil society engagement, accountability systems and technical analyst power and position. Efforts at major reform need to consider and address these issues alongside efforts to provide evidence for content decision-making. Without an analysis and understanding of the politics of reform and how to work within it, researchers and other technical actors may find their information to support reform is not applied effectively. Similarly, without an appreciation of the need for critical technical analysis to support decision making rather than an indiscriminate use of political approaches, political actors may find that even with the best of intentions, desired policy objectives may not be attained.

Building the field of health policy and systems research: social science matters.

In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences.

Building the field of health policy and systems research: framing the questions

In the first of a series of articles addressing the current challenges and opportunities for the development of Health Policy & Systems Research (HPSR), Kabir Sheikh and colleagues lay out the main questions vexing the field.

Malaria: Ethnomedical perceptions and practice in an Adangbe farming community and implications for control

Malaria is a parasitic disease about which there is much bio-medical knowledge on causation, prevention, treatment and control. Attempts at eradication, as well as control in the past has been mainly a technical and bio-medical endeavour. With the policy shift from world wide eradication of malaria to control as part of primary health care, there is increasing interest in studying all possible determinants of the problem at local as well as regional levels as part of the search for an effective intervention. This paper presents the results of a study into community perceptions and practice relating to causation, treatment and prevention of malaria in a rural Adangbe farming community in Southern Ghana. Malaria is common in this community. Crude parasite rates among adolescent girls (10-19 years old) in the community were 49% towards the end of the major rainy season, and 47% in the early dry season. The symptoms and signs of the disease are readily described by lay people as well as traditional healers. Diagnosis and treatment of uncomplicated episodes of malaria at home, according to ethnomedical perceptions, is the predominant behaviour in this community. Very few cases of uncomplicated malaria are sent to health facilities. Ethnomedical perceptions of malaria causation and treatment on which this self care is based, are different from conventional biomedical ones. Malaria is perceived as an environmentally related disease caused by excessive contact with external heat which upsets the blood equilibrium. Many community members do not connect it with the mosquito in theory or practice. Implications for approaches to control are discussed.

Improving adherence to malaria treatment for children: the use of pre-packed chloroquine tablets vs. chloroquine syrup

Malaria is a major cause of morbidity and mortality among children under five in sub‐Saharan Africa. Prompt diagnosis and adequate treatment of acute clinical episodes are essential to reduce morbidity and prevent complications and mortality. In many countries, chloroquine syrup is the mainstay of malaria treatment for children under five. Not only is syrup more expensive than tablets, adherence to the prescribed dose at home is a problem because mothers use wrongly sized measuring devices or have difficulty with the instructions. We investigated the impact of introducing pre‐packed tablets for children on adherence to treatment and compared the total cost of the tablets with that of syrup. Children aged 0–5 years diagnosed with malaria at the clinic over a 6‐week period received either pre‐packed tablets or syrup by random assignment. The principal caregivers were interviewed at home on day 4 after attending the clinic. Of the 155 caregivers given pre‐packed tablets, 91% (n=141) adhered to the recommended dosage, while only 42% (n=61) of 144 who were provided syrup did. Only 20% of caregivers who received syrup used an accurate 5 ml measure. The cost of treatment with tablets was about one‐quarter that of syrup and 62% (n=96) of caregivers preferred tablets. Pre‐packed chloroquine tablets are a viable alternative to syrup.

Building the field of health policy and systems research: an agenda for action.

In the final article in a series addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Sara Bennett and colleagues lay out an agenda for action moving forward.

Republished research: Implementation research: what it is and how to do it: implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it.

Implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it

Strategies to improve adherence to recommended chloroquine treatment regimes: a quasi-experiment in the context of integrated primary health care delivery in Ghana

This paper presents the results of an intervention study carried out as part of the activities of a District Health Management Team responsible for integrated primary health care delivery in a rural district in Ghana. The aim was to test the impact of a combination of improved information provision to patients and drug labeling on adherence to recommended anti-malarial treatment regimens focusing on oral chloroquine, for the outpatient management of acute uncomplicated malaria. The study had a quasi-experimental pre-test post-test control group design with partly random allocation by clinic. The results show that the intervention resulted in an improved flow of information to clients prescribed chloroquine, and better labeling of drugs for the home treatment of acute clinical episodes of malaria in the intervention area. Improvements in adherence occurred in all clinics. However, improvements in adherence were most marked in the clinic that was worst performing at the start of the intervention. Implications of the results for improving adherence to chloroquine therapy on an outpatient basis are discussed.

We charge them; otherwise we cannot run the hospital front line workers, clients and health financing policy implementation gaps in Ghana

OBJECTIVES This paper examines policy implementation gaps of user fees plus exemptions and health insurance in providing financial access to primary clinical care for children under five in Ghana. METHODS Methods included analysis of routine data, focus group discussions, in-depth interviews, and administration of a structured questionnaire. RESULTS Providers modified exemptions policy implementation arrangements, sometimes giving partial or no exemptions. Clients who knew or suspected exemption entitlements failed to request them because of fear of negative reactions from providers. Providers attributed their modification of implementation arrangements and negative reactions to the threat posed to the financial viability of their institutions by reimbursement uncertainty and delays. At the time of the study insurance coverage was low and frontline workers were not noticeably modifying implementation arrangements. However, the underlying goal conflicts, resource scarcity, conditions of work and relationships between frontline workers and clients that fueled the exemptions policy implementation gaps were unchanged. The potential for the health insurance policy to stumble over implementation gaps as happened with the exemptions policy therefore remained. CONCLUSIONS Policies that do not take into account the incentives for frontline worker adherence and align them better with policy objectives may experience implementation gaps.